the thoughts of a surgeon in the notorious province of mpumalanga, south africa. comments on the private and state sector. but mostly my personal journey through surgery.

Tuesday, June 29, 2010

sand through your fingers

something that still gives the old adrenals a squeeze and a vicious kick is the opening of a blunt abdominal trauma patient with a severe internal bleed. but it is so much more than just an adrenaline rush.

the scene must be set. a patient arrives in casualties after having been involved in a massive accident. often there would be people who passed away at the scene who bypass casualties altogether on their way to the morgue. more often than not, some of these people are related to your patient, but that is something to deal with tomorrow. today's efforts need to be completely focused on getting your patient through his ordeal alive.

in casualties everything is a blur of activity. someone is tasked with getting lines up while someone else orders the bloods needed and someone else phones ahead to get theater ready. decisions need to be made about whether intubation is immediately necessary or if it can wait until theater. sometimes there is distraught family outside. they wait expectantly at the door hoping for good news. i make a point of speaking to them if i can before theater. yes, my job is primarily to get the patient through the other side alive, but in the end we are alive so we can live and part of life is love and family. they need to feel like they are at least involved, even if on a very small minor level. also they need to have an idea that things may not turn out well before the time.

on the way to theater, if the patient is not intubated or if we are not doing active cardiac massage, i often peel off to the change room and rejoin the activity as the anaesthetist receives the patient in the theater entrance area. i help with getting the patient onto the bed and then...well then i take a moment. it is a moment before the storm. it is a time when i try to prepare myself for the fight ahead. i also often think about the dissociation between the humanity and the biology of what is about to happen. it is always poignant for me to think that during the operation i will be totally focused on getting the life threatening problem fixed and i will have no place to reflect on the bigger picture. i won't have time to wonder what the person is like or what his hopes and dreams are or who is praying for him to pull through. yes, i won't be able to see him as human until it's all over.

once the gas monkey has everything ready we prepare to open the abdomen. there is a certain technique to doing this otherwise fairly routine action in these types of patients. everything is opened except the peritoneum which is left to last so there is at lease a bit of pressure still on the area of bleeding. then the peritoneum is opened and all hell breaks loose.

the peritoneum is opened from top to bottom in less than a second. masses of blood come pouring out in a wild torrent and abdominal swabs are shoved with little ceremony into the abdomen, starting in the upper quadrants and moving to the lower quadrants. this is a moment that can't be fully appreciated unless you have experienced it. there is shouting and a flurry of activity. any observer will be left with the clear impression that we are fighting for the patient's life. there can be no doubt.

once the swabs are all in and the worst of the blood has stopped flowing it is time to address the source. i usually pray it is the spleen because it can be removed and the problem is solved. the liver bleeders can be a lot more tricky. a massive tear of the liver can bleed copiously. it is relatively easy to control the blood supply to the liver but the venous drainage is a different beast. the liver drains via three veins directly into the inferior venacava, the biggest baddest vein in the body. retrograde flow through a torn hepatic vein or worse an avulsion of the liver off the ivc itself may even be impossible to control.

with these sorts of injuries the amount of blood in the abdomen is so much when you push your hands into the abdomen to apply the swabs or to give direct pressure your entire arm disappears into the pool of blood way above the gloves. blood then runs down your arm on the inside of the gloves filling the gloves with blood and totally soaking your hand. your hand ends up inside a sort of latex balloon full of the life sustaining blood of your patient. at that moment you are so close to him in so many ways. his life essence is on your hands. sometimes it feels like it is slipping through your fingers and no matter what you do the inevitability of the end seems predetermined. somehow the blood on your hands feels appropriate.

often at this stage of the fight, if the anaesthetist has managed to keep up his fluid and blood administration with the blood loss he may start hinting that things are looking dismal. he may, for instance hold up yet another pint of blood from the blood bank and casually remark

"would you like me to run this through the patient first or should i just pour it out directly onto the floor?" sometimes one has to stop and acknowledge the writing on the wall.

ironically as the awareness of the unvanquished foe sets in, the humanity of it all comes flooding back in torrents that rival the previous blood flow. suddenly you wonder about the patient as a person and how futile it all seems. suddenly you wonder about your own life and that it is dependant on this flimsy body working properly and may be so easily snuffed out. suddenly you think about the expectation the family has of you saving his life, even as that life flows out of the body beneath your bloody hands. the tension i feel then far exceeds any adrenal rush i get at the dramatic opening of the abdomen and during the valiant fight for a fellow human being's life.

12 comments:

Outstanding writing and as usual,human and reflective.On a technical note,as HIV's spread intensified,I remember in the Trauma Unit at the Joburg Gen,that we wore vets examination gloves...that came up to just above the elbow...under the sterile gown and gloves which gave at least some minimal level of protection although I appreciate that double-gloving can get in the way of precise surgery vs the cut-and-slash of a resus room.Any thoughts?

mal, in a standard operation a theater gown and gloves are enough. these massively bleeding abdomens you don't see that often so there isn't really a general need for more protective gear.having said that the thoughts of the hiv risk when you take the gloves off and see the blood permeating every pore of your skin are immense. somehow, especially when the patient is dead, it seems to take a back seat. in fact i have even felt guilty for thinking about it which, in retrospect is stupid.

one pair of gloves is definitely better than two in surgery for dexterity and sensation.

ophelia, no i haven't.

viva, the monkey that gives the gas. admittedly here it is usually only oxygen.ook bekend as die gaskunstenaar of gasheer. in jou geval, gasvrou.

can you do a shronk? just use a bit of old chest drain. i dont know SA docs always say they used to put in 30 chest drains a night. however i reckon its just talk. like everyone says northern ireland doctors are good with knee trauma

I don't know whether they could keep up, but I wonder whether the Cellsaver systems available might be able to mitigate throwing blood on the floor, so to speak. Even in a place like SA, the savings in wasted blood might make this worthwhile.

From the point-of-view of someone who ended up far from surgery, far from a trauma unit, this all seems like science fiction, where one expects some kind of upending of the normal logic with bizarre and nonsensical outcomes.

Working on healthcare and medical career is indeed not an easy job. You are handling a person's life and that makes doctors and nurses a profession that has a great responsibility on life and death. Helping others survive or be healed could also be a mirror of our own survival in this world, that there will come a time that we will also live or die like our patients, eh.

Thank you Bongi for providing a link here. 2 other people did as well and I appreciate that.

You have such a way of telling the poignant moments in and out of the OR. This was riveting. Arms deep in blood. has to be a calling and a gift.

"at that moment you are so close to him in so many ways. his life essence is on your hands. sometimes it feels like it is slipping through your fingers and no matter what you do the inevitability of the end seems predetermined. somehow the blood on your hands feels appropriate."

There are moments in life that transcend words, but you describe them with such eloquence. Beautiful.

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the aim of this blog is to give insight into the mind of a particular surgeon, me. although every story is loosely based on fact, patients have been changed suitably to protect their identity. the opinions expressed are mine alone and are not meant to be considered medical advice or the opinion of any institution.